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2 Program Key DatesAQI PCP Backgrounder (program description document) Posted to POIT and Quality Site Annually During DecemberComplete Annual Survey by February 28th Following Measurement YearAnnual Scorecards Will be Posted to POIT by May 31stAQI Earned Reward Will be Effective July 1st Following the Measurement Year2013 Measurement Year reward effective with Date of Service 7/1/2014 through 6/30/2015

3 Program Overview New Web Site – POITNew Annual Survey – How To CompleteProgram Key Dates

4 Where to Find AQI Program InformationProvider Online Interactive Tool (POIT)Replaced original AQI Web Portal in 2012POIT access requires specific user name and passwordHow to access POITAnthem.com>Provider>Provider Home>select state>Provider Online Interactive Tool>Rewards & Recognition>Sign On>EnterClick on View Programs folder at bottom of the program pageSelect Quality-In-Sights® by clicking on the drop down arrowHere you find the annual survey

9 External Recognition ContinueNCQA ProgramsDiabetes Physician Recognition Program (DPRP)Heart/Stroke Recognition Program (HSRP)Back Pain Recognition Program (BPRP)Recognition require support documentation.If you check off Yes to any program you must submit a list of the physicians names no later than February 28, On POIT, Anthem will auto fill the physicians with in your group. As well as the space to enter the program name and certificate start and end dates.

10 Clinical Improvement QuestionDid at least one physician within a Tax ID actively participate in a national or state quality improvement collaborative or practice improvement activity during the measurement year January 1, through December 31, 2013?If you checked YES, please indicate which Clinical Collaborative(s) or Practice Improvement activityAnthem will continue to recognize applicable collaborative (state or national) or practice improvement activities that the provider or provider practice improvement activities that the physician or physician practice participated in during the measurement period January 1, 2013 – December 31, 2013

13 Recap of Program Key DatesAQI PCP Backgrounder (program description document) Posted to POIT and Quality Site Annually During DecemberComplete Annual Survey by February 28th Following Measurement YearAnnual Scorecards Will be Posted to POIT by May 31stAQI Earned Reward Will be Effective July 1st Following the Measurement Year2013 Measurement Year reward effective with Date of Service 7/1/2014 through 6/30/2015

17 HIPAAUnder the Health Information Portability and Accountability Act (HIPAA) Privacy Rule, data collection for HEDIS is permitted and the release of this information requires no special patient consent or authorization. Please be assured our members’ personal health information is maintained in accordance with all federal and state laws. Data is reported collectively without individual identifiers. All of the health plans’ contracted providers’ records are protected by this.Data collection for HEDIS is permitted and the release of this information requires no special patient consent or authorization.

18 What is HEDIS? HEDIS (HĒ · DIS) Healthcare Effectiveness Data andHEDIS is a performance measurement tool that is coordinated and administered by NCQA (National Committee for Quality Assurance)It is used by more than 90% of America's health plansManaged care companies who are NCQA accredited perform HEDIS reviews the same time each yearNCQA has set a deadline of May 15 for health plans to gather HEDIS dataRetrospective review of services and performance of careResults are used to measure performance, identify quality initiatives, and provide educational programs for providers and membersHEDIS (HĒ · DIS)HealthcareEffectivenessData andInformationSet

19 What is your role in HEDIS?You play a central role in promoting the health of our membersYou and your office staff can help facilitate the HEDIS process improvement by:Providing the appropriate care within the designated timeframesDocumenting all care in the patient’s medical recordAccurately coding all claimsResponding to our requests for medical records within 5 business daysWhat is your role in HEDIS?With the new May 15 deadline, it’s important that offices respond to our request in 5 business days. If we get the information we need the first time and on time, we will not need to keep calling your office. We realize you are very busy and we do not want to cause provider abrasion.We appreciate your cooperation and timeliness in submitting the requested medical record informationThe records that you provide us during this process helps us to validate the quality of care provided to our members.

20 Jan-May 15 June September Annual HEDIS CalendarClinical Quality Staff collects HEDIS data (Medical Record Reviews)JuneResults are reported to NCQASeptemberNCQA releases Quality Compass results nationwideEmphasize that no data will be accepted after the 5/15 deadline.Emphasize that for P4P data must be received prior to the 5/15 deadline. (optional for P4P states)NCQA has set a deadline of May 15 for health plans to gather HEDIS data

21 Types of Reviews HEDIS data are collected three ways:Administrative Data: Obtained from our claims databaseHybrid Data: Obtained from our claims database and medical record reviewsSurvey Data: Obtained from member and provider surveysTypes of ReviewsHybrid: Clinical Quality staff conduct medical record reviews on members selected for these measures. This allows us to capture missing information and improve HEDIS rates

22 Medical Record RequestsMedical Record Requests are faxed to providersThe request includes a member list identifying their assigned measures and information neededData collection methods include: fax, mail, onsite for larger requests, remote electronic medical record (EMR) system access, and electronic data interchange via FTP siteDue to the shortened data collection timeframe, a five-day turnaround is expectedPlease send only the necessary data vs. sending the entire chart. Where applicable, we will send offices a Provider Abstraction Form allowing the office staff to write in the dates & results, thereby eliminating the need to copy charts.EMR:If you have EMRs and would be interested in electronic data submission, please contact your state lead to see if it is possible with your systemWe recommend uploading records to our FTP site to allow for better tracking of information submitted.

24 Questions & Answers How to improve scores for HEDIS measures?Use of correct diagnosis and procedure codes, timely submission of claims and encounter data, ensure presence of ALL components in the medical record documentationHow are HEDIS rates communicated to physicians?Educational articles are included in provider newsletters, which can be found on the health plan’s websiteWhere can I get more information about NCQA and HEDIS?More information can be found atWho do I contact if I have questions about HEDIS requests?Each medical record request includes contact information for a member in Clinical Quality who is assigned to your office. You may contact them or the HEDIS Team Lead for your state

26 ABA – Adult BMI Assessment Documentation must include:BMI (body mass index): Date and ValueWeight: Date and ValueCommon Chart Deficiencies:Height and/or weight are documented but there is no calculation of the BMINEW: Ranges and thresholds are no longer acceptable for this measure. A distinct BMI value or percentile is requiredABA –Adult BMI AssessmentMay use BMI percentile for members younger than 19 years on date of serviceMembers age who had an outpatient visit with a BMI documented during the measurement year or the year prior

27 Adolescent Well-Care Visits*Documentation must include:Health and developmental history (physical and mental)Physical examHealth education/anticipatory guidanceCommon Chart Deficiencies:Lack of documentation of education and anticipatory guidanceAdolescents being seen for sick visits only and no documentation related to well- child visitsAWC –Adolescent Well-Care Visits*Preventive services may be rendered on visits other than well-child visits.Members years old in the measurement year that have had at least ONE “Well Care” visit with a PCP or OB/GYN (school physical, pap, post partum visit) during the measurement year*Medicaid

28 Controlling High Blood PressureCBP –Controlling High BloodPressureDocumentation must include:Date of Hypertension diagnosis on or before June 30th of the measurement yearLast BP Reading (date and result) in the measurement yearCommon Chart Deficiencies:Rechecked elevated pressures during the same visit not documentedDiagnosis date of hypertension is not clearly documentedDiagnosis can be from progress note, problem list, consult note, hospital admission or dischargeMembers years old with diagnosis of Hypertension prior to June 30th of the measurement year

29 CCS – Cervical Cancer Screening* Documentation must include:Date and result of cervical cancer screening test –or-Date and result of cervical cancer screening test and date of HPV test (NEW) –or-Evidence of hysterectomy with no residual cervixCommon Chart Deficiencies:Lack of documentation related to women’s health in PCP chartsIncomplete documentation related to hysterectomyCCS –Cervical Cancer Screening*Female members during the measurement timeframe (measurement year and two years prior) who had cervical cancer screening –or –Female members ages who had cervical cancer screening and HPV test (measurement year and four years prior) (NEW)*Commercial/Medicaid

30 Comprehensive Diabetes CareCDC –Comprehensive Diabetes CareDocumentation must include:Hemoglobin A1C*LDL Lipid Screening*Blood Pressure*Nephropathy: Urine Tests, ACE/ARB prescription, or visits to nephrologistsRetinal Eye Exam (during the measurement year or year prior)*Date and result of last screening in the measurement yearCommon Chart Deficiencies:Incomplete information from consultants in the PCP chartsIncomplete information related to yearly lab testing and resultsMembers with Type I and II Diabetes who received proper testing and care for diabetes during the measurement year

31 Documentation must include:CIS –Childhood ImmunizationStatusDocumentation must include:4 DTAP3 IPV3 HIB3 HEP B1 MMR4 Pneumococcal (PCV)1 HEP A2 Influenza2 or 3 Rotavirus/RVRotarix = 2 doseRota Teq = 3 dose1 VZV or has had chickenpoxIf missing any immunizations, please include:Documentation of parental refusalDocumentation of request for delayed immunization schedulesImmunizations given at health departmentsImmunizations given in the hospital at birthDocumentation of contraindications or allergiesPercentage of children 2 years of age who had all of the required immunizations

32 Childhood Immunization StatusCIS –Childhood ImmunizationStatusCommon Chart Deficiencies:Immunizations received after the 2nd birthdayPCP charts do not contain immunization records if received elsewhereHealth DepartmentsImmunizations that are given in the hospital at birthNo documentation of Contraindications/AllergiesPercentage of children 2 years of age who had all of the required immunizations

33 Documentation must include:LSC –LeadScreening in Children*Documentation must include:A note indicating the date the test was performed, andThe result or findingCommon Chart Deficiencies:Lead assessment does not constitute a lead screeningThe result or finding.The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday*Medicaid

34 Documentation must include:CMC -Cholesterol Management for Patients with Cardiovascular ConditionsDocumentation must include:LDL Lipid Screening (date and result)LDL control is <100 mg/dLCommon Chart Deficiencies:Incomplete information from consultants in the PCP chartsIncomplete information related to yearly lab testing and resultsCholesterol management for members age who were diagnosed with a cardiovascular condition as of December 31st of the measurement year

35 Documentation must include:COL -Colorectal Cancer ScreeningDate and result of one of these screenings:Colonoscopy (within last 10 years)FOBT (in measurement year)Flexible Sigmoidoscopy (within last 5 years)Common Chart Deficiencies:Colorectal screenings are not consistently documented in health historiesTypically this information is included on health history forms however this information is not always provided as part of the record submissions.Patient reported data noted on a medical record is sufficient evidence with date and results noted.Members age who had appropriate screening for colorectal cancer

36 Human Papillomavirus Vaccine for Female AdolescentsHPV –Human Papillomavirus Vaccine for Female AdolescentsDocumentation must include:3 HPV shotsCommon Chart Deficiencies:HPV vaccines administered prior to a member’s 9th birthday and after the 13th birthday cannot be countedPCP charts do not contain immunization records if received elsewhere, i.e. Health DepartmentsIncomplete series of three immunizations not receivedIf immunizations are missing please include:Documentation of parental refusalHealth Department recordsPatient Contraindications/allergiesFemale adolescent members who had 3 doses of the HPV vaccine between their 9th and 13th birthdays

37 Documentation must include:FPC -Frequency of Ongoing Prenatal Care*Documentation must include:Date and documentation of all prenatal visitsMost of this information is found on the ACOG sheetsFemale members who delivered a live birth on or between November 6 of prior year to November 5 of the measurement year and were continuously enrolled 42 days prior to delivery*MedicaidDo we want to mention ACOG sheets?

38 IMA- Immunizations for AdolescentsDocumentation must include:Meningococcal: 1 dose on or between 11th & 13th birthdaysTdap/TD: 1 dose on or between 10th & 13th birthdaysCommon Chart Deficiencies:Immunizations not administered during appropriate timeframesPCP charts do not contain immunization records if received elsewhere, i.e. Health DepartmentsIf immunizations are missing please include:Documentation of parental refusalHealth Department recordsPatient Contraindications/allergiesAdolescent members turning 13 in the measurement year who had these immunizations

39 Documentation must include:PPC -Prenatal and Postpartum CarePrenatal Care: Prenatal visit within 42 days of enrollment or during the first trimesterPostpartum Care: Post-partum visit within days of deliveryCommon Chart Deficiencies:Incision check for post C-section does not constitute a postpartum visitFemale members who delivered a live birth between November 6 of the year prior and November 5 of the measurement year

40 Documentation must include:WCC –Weight Assessment & Counseling for Nutrition & Physical Activity for Children/AdolescentsBMI (body mass index) PercentileBMI Percentile date and valueMay be a BMI value for adolescents age on date of serviceRanges and thresholds do not meet the criteria for this measure (NEW)Weight date and valueHeight date and valueCounseling for Nutrition: Discussion on diet and nutrition, anticipatory guidance or counseling on nutritionCounseling for Physical Activity: Discussion of current physical activities, counseling for increased activity, or anticipatory guidance on activityMembers age 3-17 who had an outpatient visit with the following components in the measurement year

41 Common Chart Deficiencies:WCC –Weight Assessment & Counseling for Nutrition & Physical Activity for Children/AdolescentsCommon Chart Deficiencies:BMI documented as number not percentile based on height, weight, age and genderAnticipatory guidance does not always specify what areas were addressed and are not always age appropriateDevelopmental milestones do not constitute anticipatory guidance or education for physical activityPreprinted forms do not always address nutrition and physical activityMembers age 3-17 who had an outpatient visit with the following components in the measurement year

42 W15 – Well Child Visits in the First 15 Months of Life*Documentation must include:Health and developmental history (physical and mental)Physical examHealth education/anticipatory guidanceCommon Chart Deficiencies:Lack of documentation of education and anticipatory guidanceChildren being seen for sick visits only and no documentation related to well-child visitsPreventive services may be rendered on visits other than well-child visits.Children 0-15 months of age during the measurement year who had 6 or more well-child visits*Medicaid

43 Well Child Visits in the 3rd, 4th, 5th & 6th Years of Life*Documentation must include:Health and developmental history (physical and mental)Physical examHealth education/anticipatory guidanceCommon Chart Deficiencies:Lack of documentation of education and anticipatory guidanceChildren being seen for sick visits only and no documentation related to well-child visitsPreventive services may be rendered on visits other than well-child visits.Children 3-6 years old in the measurement year that have had at least ONE “Well Care” visit with a PCP during the measurement year*Medicaid

44 Summary List of HEDIS MeasuresAppendix 2Summary List of HEDIS MeasuresCOMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY

46 Summary List of HEDIS MeasuresApplicable to:Data SourceCommercialMedicaidMedicareEffectiveness of CareAvoidance of Antibiotic Treatment in Adults With Acute BronchitisAdminUse of Spirometry Testing in the Assessment and Diagnosis of COPDPharmacotherapy Management of COPD ExacerbationUse of Appropriate Medications for People With AsthmaMedication Management for People With AsthmaAsthma Medication RatioCholesterol Management for Patients With Cardiovascular ConditionsHybridControlling High Blood PressurePersistence of Beta-Blocker Treatment After a Heart AttackComprehensive Diabetes CareDisease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid ArthritisOsteoporosis Management in Women Who Had a FractureUse of Imaging Studies for Low Back Pain

47 Summary List of HEDIS MeasuresApplicable to:CommercialMedicaidMedicareData SourceEffectiveness of CareAntidepressant Medication ManagementAdminFollow-Up Care for Children Prescribed ADHD MedicationFollow-Up After Hospitalization for Mental IllnessDiabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic MedicationsDiabetes Monitoring for People With Diabetes and SchizophreniaCardiovascular Monitoring for People With Cardiovascular Disease and SchizophreniaAdherence to Antipsychotic Medications for Individuals With SchizophreniaAnnual Monitoring for Patients on Persistent MedicationsMedication Reconciliation Post-Discharge (SNP only)Potentially Harmful Drug-Disease Interactions in the Elderly

50 Summary List of HEDIS MeasuresApplicable to:Data SourceCommercialMedicaidMedicareUtilization and Relative Resource UseInpatient Utilization—General Hospital/ Acute CareAdminIdentification of Alcohol and Other Drug ServicesMental Health UtilizationAntibiotic UtilizationPlan All-Cause ReadmissionsGuidelines for Relative Resource Use MeasuresRelative Resource Use for People With DiabetesRelative Resource Use for People With Cardiovascular ConditionsRelative Resource Use for People With HypertensionRelative Resource Use for People With COPDRelative Resource Use for People With Asthma

53 Documentation RequirementsHEDIS® Measurement 2014 Physician Documentation Guidelines and Administrative CodesHEDIS MeasureMember DescriptionDocumentation RequirementsCodesAspirin Use and Discussion (ASP) CAHPS SurveyWomen 56–79 years of ageMen 46–79 years of ageAssessing average aspirin use and management in members with risk factors for cardiovascular disease and discussing aspirin risks and benefits with their doctor or health provider.This measure is collected using consumer survey methodology.Breast Cancer Screening (BCS) Medicare Health Plan Rating Measure50-74 year old womenOne or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year.CPT®:ICD-9-CM: , 87.37HCPCS: G0202, G0204, G0206UB Revenue: 0401, 0403Cervical Cancer Screening (CCS)Women age who had cervical cytology performed every 3 yearsWomen age who had cervical cytology/HPV co-testing performed every 5 yearsEvidence of cervical cytology within last 3 years (date and result)For women that do not meet above criteria, evidence of cervical cytology and an HPV test on the same date of service during the measurement year or the four years prior to the measurement year. (date and result)CPT®: , 88147, 88148, 88150, , , 88174, HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q UB Revenue: 0923Same codes as above and CPT®:

57 Documentation RequirementsHEDIS® Measure 2014 Physician Documentation Guidelines and Administrative CodesHEDIS MeasureMember DescriptionDocumentation RequirementsCodesControlling High Blood Pressure (CBP) Medicare Health Plan Rating Measure18-85 year old members with diagnosis of hypertensionDiagnosis: Date of diagnosis of hypertension before June 30 of the measurement year andLast BP reading (date & result) in the measurement year (if elevated, document all BP readings)Hypertension diagnosis: ICD-9-CM: 401, 401.0, 401.1, 401.9Disease-modifying Antirheumatic Drug (DMARD) Therapy for Rheumatoid Arthritis (ART)Medicare Health Plan Rating MeasureMembers diagnosed with rheumatoid arthritis and dispensed at least one ambulatory prescription for a DMARD in 2012Assess all members with diagnosis of rheumatoid arthritis for DMARD treatment in 2013All members not currently treated with a DMARD should be referred for rheumatology consultation to confirm diagnosis and assess for DMARD therapyDMARDS include:Aminoquinolines: Hydroxychloroquine5-Aminosalicylates: SulfasalazineAlkylating agents: CyclophosphamideAntirheumatics: Auranofin, gold sodium thiomalate, leflunomide, methotrexate, penicillamineImmunomodulators: Abatacept, adalimumab, anakinra, certolizumab, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, TocilizumabImmunosuppressive agents: Azathioprine, cyclosporine, mycophenolateTetracyclines: MinocyclineJanus kinase inhibitor (JAK): TofacitinibCodes To Identify Rheumatoid Arthritis:ICD-9-CM: , 714.1, 714.2,AND/ORPharmacy claim for DMARD in 2013Follow-up After Hospitalization for Mental Illness (FUH)Members 6 years and older with a follow up visit after hospitalization for mental illnessThe percentage of discharges for members who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, intensive outpatient encounter of partial hospitalization with a mental health practitioner.The percentage of discharges for which the member received follow-up within 7 days and 30 days of dischargeICD-9-CM: , 300.3, 300.4, 301, 308, 309,

58 Documentation RequirementsHEDIS® Measure 2014 Physician Documentation Guidelines and Administrative CodesHEDIS MeasureMember DescriptionDocumentation RequirementsCodesFlu Vaccinations for Adults (FVU) CAHPS Survey18-85 year old membersThe percentage of members who received an influenza vaccination between July 1, 2013 and the date when the survey was completed.This measure is collected using consumer survey methodology.Frequency of Ongoing Prenatal Care (FPC)Women who delivered a live birth between November 6 of the year prior to the measurement year and November 5 of the measurement yearAll prenatal records for a delivery that occurred between November 6 of the year prior to the measurement year and November 5 of the measurement yearCPT®: 59400, 59425, 59426, 59510, and 59618Getting Needed Care CAHPS SurveyAll membersMembers experience getting needed care; appointments with specialists, tests, or treatment.Glaucoma Screening in Older Adults (GSO)Medicare Health Plan Rating MeasureMembers 65 years old or older who received a glaucoma screening examRefer and encourage members 65 years old and older who did not have a claim/encounter for glaucoma screening in 2012 to see an eye care professional for glaucoma screening in 2013.Must be done by an ophthalmologist or optometrist and submitted for 2012 or 2013Codes to Identify Screening Exams:CPT®: 92002, 92004, 92012, 92014, , 92100, 92120, 92130, 92140, , ,HCPCS: G0117, G0118, S0620, S0621Human Papillomavirus Vaccine for Female Adolescents (HPV)13 year old female adolescents3 doses of HPV vaccine administered between ages 9 and 13 years oldCPT®: 90649, 90650Immunizations for Adolescents (IMA)13 year old adolescentsVaccines administered on or before their 13th birthday:1 MCV/meningococcal vaccine between 11th & 13th birthdays and1 or 1 Td vaccine between their 10th and 13th birthdaysMeningococcal CPT:® and 90734Tdap CPT®:Td CPT:® and 90718Tetanus CPT:® 90703Diphtheria CPT:® 90719Lead Screening in Children (LSC)Members 0-2 years of ageLab/value and date for venous or capillary blood lead screeningCPT®: 83655

65 THANK YOU FOR ATTENDING TODAY’S PRESENTATION!Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.